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There is a notable disparity in sport-related injuries between sexes, with females sustaining non-contact musculoskeletal injuries at a higher rate. ISEH Clinical Director and Consultant Orthopaedic Surgeon Professor Fares Haddad together with esteemed Sport and Exercise Medicine Physicians Rhody D. Raj, Andreas Fontalis, Tarani Sai Prasanth Grandhi, Woo J. Kim and Ayman Gabr, have published research investigating the complex interplay between the menstrual cycle and orthopaedic sports injuries in pre-menopausal female athletes. This study provides deeper insights into this critical issue and proposes preventative strategies aimed at mitigating injury risks.

Anterior cruciate ligament (ACL) ruptures are two to eight times more common in females than in males and females also have a higher incidence of ankle sprains, patellofemoral pain and bone stress injuries. The effects of such injuries can be devastating, leading to time out of sport, surgery and the early onset of osteoarthritis.
The research revealed that the incidence of sports injuries in female athletes is influenced by various factors, including biomechanical differences and hormonal influences. Key findings indicate that relaxin, a hormone known to increase ligamentous laxity, significantly heightens the injury risk during certain menstrual phases. Oestrogen is found to decrease collagen synthesis in ligaments, potentially leading to a higher susceptibility to injuries like ACL tears. In contrast, progesterone is noted for stabilizing ligament structures, potentially offering a protective role.

While some contributing factors are inherent, certain hormonal elements can be modified to reduce risks. Raising awareness among coaches, physiotherapists, nutritionists, doctors, and athletes is crucial for preventive measures, as neglected modifiable risk factors can lead to fatigue, poor performance, and an increased risk of injury. The study proposes evidence-based recommendations focusing on diet, menstrual function, bone mineral density, and psychological aspects.
A critical aspect of the research is the emphasis on the 'female athlete triad', relating to energy availability, menstrual function and bone mineral density. Regular screening for dietary restrictions, low BMI, menstrual irregularities and eating disorders in female athletes is emphasized. While some authors suggest a potential protective effect of oral contraceptive pills on ACL injuries, their use as a prophylactic solution is not universally recommended due to conflicting evidence and associated complications.

Recommendations also include the development of training and nutrition programs tailored to the different phases of the menstrual cycle. The implementation of pre-season and in-season physiotherapy programs, such as the Santa Monica PEP program, has shown significant reductions in injury risks. Plyometrics, combined with neuromuscular and proprioceptive exercises, are effective in reducing ACL injury risks. The use of prophylactic knee braces is suggested on an individual basis, considering the conflicting results.

In conclusion, future research should expand beyond the ACL to explore the impact of the menstrual cycle on other frequently injured areas. Large-scale epidemiological studies and biochemical research are recommended to deepen our understanding of injuries in female athletes. Long-term evaluations of screening and prevention programs will guide resource allocation, contributing to the overall reduction of injury risks in female athletes.

For more information, read the publication in the Bone and Joint Journal.